MATERNITY HESI ASSIGNMENT EXAM
1. Which finding in the medical history of a post-partum client should the nurse
withhold the administration of a routine standing order for methylergonovine
maleate (Methergine)?*Answer√√ Pregnancy induced hypertension.
Rationale
Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension is a contraindi-
cation for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order
should be withheld and reported to the healthcare provider.
2. A client at 8-months gestation tells the nurse that she knows her baby listens
to her, but her husband thinks she is imagining things. What information
should the nurse provide?
*Answer√√ The fetus in utero is capable of hearing and does respond to the mother's voice.
Rationale
Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound
of the mother's voice.
,3. A female client who wants to delivery at home asks the nurse to explain the
role of a nurse-midwife in providing obstetric care. What information should
the nurse provide?*Answer√√ The pregnancy should progress normally and be considered low risk.
Rationale
A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric
client.
4. What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal ?
*Answer√√ Swaddle the infant snugly and hold tightly.
Rationale
An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to
reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability.
5. The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
*Answer√√ Avoid alcohol because it is excreted in breast milk.
,Rationale
Alcohol should be avoided while breastfeeding because, when consumed by the mother, it is excreted in breast milk.
6. A primigravida at 12-weeks gestation who just moved to the United States
indicates she has not received any immunizations. Which immunization(s)
should the nurse administer at this time? (Select all that apply.)
Tetanus.
Rubella.
Diphtheria.
Chickenpox.
Hepatitis B.
*Answer√√ Correct selections are (A, C, and E).
Rationale
Vaccines composed of killed viruses may be administered during pregnancy. Rubella (B) and chickenpox (D) consist
of live or attenuated live viruses which would be contraindicated during pregnancy due to potential teratogenicity.
, 7. A client at 25-weeks gestation tells the nurse that she dropped a cooking
utensil last week and her baby jumped in response to the noise. What infor-
mation should the nurse provide?
*Answer√√ The fetus can respond to sound by 24-weeks gestation.
Rationale
At 24-weeks gestation, the fetus's ability to hear loud environment sounds can illicit a startle response.
8. A client at 28-weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?
*Answer√√ - Changes in fetal heart rate patterns.
Rationale
Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a
pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia
due to internal bleeding in the mother.
9. The nurse is discussing the stages of labor with a group of women in the last
1. Which finding in the medical history of a post-partum client should the nurse
withhold the administration of a routine standing order for methylergonovine
maleate (Methergine)?*Answer√√ Pregnancy induced hypertension.
Rationale
Methergine is used for post-partum bleeding. A client's history of pregnancy-induced hypertension is a contraindi-
cation for Methergine which causes vasoconstriction and increases blood pressure, so the routine standing order
should be withheld and reported to the healthcare provider.
2. A client at 8-months gestation tells the nurse that she knows her baby listens
to her, but her husband thinks she is imagining things. What information
should the nurse provide?
*Answer√√ The fetus in utero is capable of hearing and does respond to the mother's voice.
Rationale
Fetal hearing and response to sound occurs by 24-weeks gestation, so the fetus can be soothed by the familiar sound
of the mother's voice.
,3. A female client who wants to delivery at home asks the nurse to explain the
role of a nurse-midwife in providing obstetric care. What information should
the nurse provide?*Answer√√ The pregnancy should progress normally and be considered low risk.
Rationale
A nurse midwife is an advanced practice nurse who is prepared to provide quality perinatal care for a low-risk obstetric
client.
4. What nursing action should be included in the plan of care for a newborn
experiencing symptoms of drug withdrawal ?
*Answer√√ Swaddle the infant snugly and hold tightly.
Rationale
An infant experiencing drug withdrawal should be swaddled, wrapped snugly, or placed in a "kangaroo pouch" to
reduce self-stimulation behaviors and protect skin from abrasions that may occur due to muscular irritability.
5. The nurse is teaching a new mother about diet and breastfeeding. Which
instruction is most important to include in the teaching plan?
*Answer√√ Avoid alcohol because it is excreted in breast milk.
,Rationale
Alcohol should be avoided while breastfeeding because, when consumed by the mother, it is excreted in breast milk.
6. A primigravida at 12-weeks gestation who just moved to the United States
indicates she has not received any immunizations. Which immunization(s)
should the nurse administer at this time? (Select all that apply.)
Tetanus.
Rubella.
Diphtheria.
Chickenpox.
Hepatitis B.
*Answer√√ Correct selections are (A, C, and E).
Rationale
Vaccines composed of killed viruses may be administered during pregnancy. Rubella (B) and chickenpox (D) consist
of live or attenuated live viruses which would be contraindicated during pregnancy due to potential teratogenicity.
, 7. A client at 25-weeks gestation tells the nurse that she dropped a cooking
utensil last week and her baby jumped in response to the noise. What infor-
mation should the nurse provide?
*Answer√√ The fetus can respond to sound by 24-weeks gestation.
Rationale
At 24-weeks gestation, the fetus's ability to hear loud environment sounds can illicit a startle response.
8. A client at 28-weeks gestation experiences blunt abdominal trauma. Which
parameter should the nurse assess first for signs of internal hemorrhage?
*Answer√√ - Changes in fetal heart rate patterns.
Rationale
Hypoperfusion of the fetus may be present before the onset of clinical signs of maternal compromise or shock in a
pregnant woman, so the external fetal monitor tracings should be assessed first to determine signs of fetal hypoxia
due to internal bleeding in the mother.
9. The nurse is discussing the stages of labor with a group of women in the last
